An important article appeared in the NY Times Magazine today:
When Is a Pain Doctor a Drug Pusher?
"Ronald McIver is a prisoner in a medium-security federal compound in Butner, N.C. He is 63 years old, of medium height and overweight, with white hair and a calm, direct, intelligent manner. He is serving 30 years for drug trafficking, and so will likely live there the rest of his life. McIver is a doctor who for years treated patients suffering from chronic pain.
"Opioids have immense power — both to harm and to heal. They can be life-destroying, but high doses allow patients to work, to be with family, to be who they are. In its prosecutions of pain doctors, the government fails to recognize the duality of these drugs.
"The basis of the physician-patient relationship is trust. Trust is especially valued by pain patients, who often have long experience of being treated like criminals or hysterics. But when prescribing opioids, a physician’s trust is easily abused. Pain doctors dispense drugs with a high street value that are attractive to addicts. All pain doctors encounter scammers; some doctors estimate that as many as 20 percent of their patients are selling their medicine or are addicted to opioids or other drugs. Experts are virtually unanimous in agreeing that even addicts who are suffering pain can be successfully treated with opioids. Indeed, opioids can be lifesaving for addicts — witness the methadone maintenance therapy given to heroin addicts. But treating addicts requires extra care.
This is a strange sad article. If points to how we ignore many patients as we allow government agencies and the courts to control the management of a disabling medical problem.
Indeed, opiates have been used for centuries to control pain. In 1927, F.W. Peabody, a Boston physician, was dying of stomach cancer. During his final ordeal, Peabody wrote an article called "The Care of the Patient" which is the most cited article ever written in the medical literature. He wrote it while receiving morphine for incapacitating cancer pain. In a separate, as yet unpublished, paper Peabody wrote that with morphine "I am brought back to my best normal intellectual level and to an improved physical level." He quotes Sandoz who said that "morphine differs from other drugs in that the subject shows symptoms when he is not receiving it, rather than , like alcohol, when he is under its influence."
It is unfortunate that as a group, most physicians do not know how to prescribe opiate drugs today. Those who do are forced to use newer more dangerous (and expensive) analogs and face marginalization and prosecution. The result is that many patients are under-medicated. Perhaps, we might never have had Peabody's seminal article "The Care of the Patient" if the D.E.A. had been as powerful then as it is today.
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